Huh. Probaby my inexperience, but the amount of scenarios that requires ALS is staggering. But, perhaps it's the frequency of occurrence rather than the multitude of possible situations that require ALS .

The fire extinguisher is not just for show

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There are several types of calls that will experience in your career: those that should receive ALS, those that ALS would be nice to have and medications or interventions would be beneficial, and those where ALS is needed and if not received, the patient WILL die. And then there are those calls where ALS is not needed, the patient just needs a ride to the ER (bonus points if they are horizontal, but many could just as easily go by cab).

Experience of providers, medical director's guidelines, even geography of coverage area can affect if a provider thinks the patient should be an ALS or BLS treat.

The few studies that I have seen show that ALS treat & transport does not affect mortality of EMS patients, at least not when compared to BLS treat and transport. ALS can make the patient feel better, have an overall improvement in comfort and quality of life (and yes, at times, they can saves lives).

However there are also a ton of EMS calls that we get that a paramedic can't do more for, or might just start an IV lock and give the stare of life as the patient gets a nice ride to the ER. Take that IV lock out, and and EMT can give the stare just as well as a paramedic.

I'm not saying paramedics aren't needed, or have no place in EMS systems, but there are many areas & states that still utilize BLS ambulances with an ALS chase car, and I don't see dead bodies piling up on the streets because they don't always have paramedics on every ambulance call.

When I looked at the stats at my first EMT agency in the late 90s, out of 5,000 annual calls, maybe 20% were treated by ALS providers coming in a flycar.

Forum Deputy Chief

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Here are some small scale numbers for you. Between Sunday and 0400 this morning I ran 37 calls. I can think of 3 that absolutely needed to go to the hospital. Only 1 needed an ALS assessment as a rule out. None needed any true ALS intervention beyond 12 lead/IV.

Forum Asst. Chief

Here are some small scale numbers for you. Between Sunday and 0400 this morning I ran 37 calls. I can think of 3 that absolutely needed to go to the hospital. Only 1 needed an ALS assessment as a rule out. None needed any true ALS intervention beyond 12 lead/IV.

So maybe -- and I'm just saying, maybe -- based on what you, DrParasite and others have said, a more realistic model for EMS would be a single level of certification somewhere between medic and EMT with, say, 600-800 hours of instruction. We'd get rid of rarely used and non-essential procedures in paramedic protocols, lower scope of practice but perhaps raise quality of care within that redefined scope, and abandon force-fits like community paramedicine (best left to clinicians with more training in chronic conditions and well care). We'd also end all those arguments about degree requirements (no) and whether EMS is a profession or a trade (the latter). The effect on outcomes would be negligible, since most calls don't require ALS, and cost of prehospital care would drop.

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So maybe -- and I'm just saying, maybe -- based on what you, DrParasite and others have said, a more realistic model for EMS would be a single level of certification somewhere between medic and EMT with, say, 600-800 hours of instruction. We'd get rid of rarely used and non-essential procedures in paramedic protocols, lower scope of practice but perhaps raise quality of care within that redefined scope, and abandon force-fits like community paramedicine (best left to clinicians with more training in chronic conditions and well care). We'd also end all those arguments about degree requirements (no) and whether EMS is a profession or a trade (the latter). The effect on outcomes would be negligible, since most calls don't require ALS, and cost of prehospital care would drop.

I don’t think limiting prehospital services is anywhere near the right answer. There are situations where having a medic on scene is the best thing for the patient.

If there are no medics lost skills may include: blood products, intubation, surgical crics, RSI, needle decompression, chest tubes, sedation, pain management, 12-lead interpretation, conscious IO, etc. The answer is not to give these advanced skills that can in fact be live saving to a provider with lesser training.

I hear and I forget. I see and I remember. I do and I understand.

NVRob;388322 said:

You forget that all the activities you do hurt when you crash and I am the candyman.

Forum Asst. Chief

I don’t think limiting prehospital services is anywhere near the right answer. There are situations where having a medic on scene is the best thing for the patient.

If there are no medics lost skills may include: blood products, intubation, surgical crics, RSI, needle decompression, chest tubes, sedation, pain management, 12-lead interpretation, conscious IO, etc. The answer is not to give these advanced skills that can in fact be live saving to a provider with lesser training.

Of the skills you mentioned, I'm thinking blood products, surgical crics, RSI, and chest tubes probably wouldn't make the cut for 600-800-hour medic/EMTs. And I agree there are situations where a medic on scene is the best thing for a patient. I also think there are lots of situations where a doctor on scene would be the best thing for a patient. That's almost never an option in the U.S., but we've adapted.

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I'd disagree with lowering it as well. Just because that was what this week was like, I have also gone to the resus bay multiple times in a row with critical patients, transported GSW's multiple days in a row, been dispatched to a couple arrests in a day, etc. Those are all patients that required intubation, pressors, multiple meds for obstructive airway issues, decompressions, crics, and other things that make up the small percentage of patients where our knowledge and toolbox actually make a difference in outcomes.

I do think a mid level training as baseline is something worth thinking about being the standard, especially in areas with longer response times.

Forum Asst. Chief

I'd disagree with lowering it as well. Just because that was what this week was like, I have also gone to the resus bay multiple times in a row with critical patients, transported GSW's multiple days in a row, been dispatched to a couple arrests in a day, etc. Those are all patients that required intubation, pressors, multiple meds for obstructive airway issues, decompressions, crics, and other things that make up the small percentage of patients where our knowledge and toolbox actually make a difference in outcomes.

I do think a mid level training as baseline is something worth thinking about being the standard, especially in areas with longer response times.

You and DesertMedic have a point if you're talking about saving someone who would have forfeited life or quality of life without high-end paramedic intervention prehospitally -- i.e., prompt therapy that wouldn't be part of a 600-800-hour curriculum. I'm not sure how often that happens. I don't think I had more than a handful of cases like that in 20 years.

I don't doubt your patients needed what you did for them. I'm just wondering how many of them could have been stabilized to a lesser extent, treated definitively at a hospital, then discharged intact.

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There is the other end of the spectrum too. If you have a smaller foundation of knowledge, the way which you approach a true resus situation will be different. There is a lot to be said about knowing when to not to do something or to do it in a much more conservative manner. To do so requires understanding more of the how and why which is going to get cut out with shorter schools and lower standards.

If there was a consistently high standard, we wouldn't be fighting things like backboard at the slightest back pain, 15L NRB for a slightly low O2 sat, or flooding trauma patients with liters of saline. Yet it's still done.

I absolutely believe BLS has it's place with most of what we do and ALS is over emphasized. Where I work, it's only just now getting approved that a BLS provider can even tech a 911 call. Just don't cut the standards for ALS, restructure how we operate if anything so each one is being allocated appropriately.

Forum Asst. Chief

There is the other end of the spectrum too. If you have a smaller foundation of knowledge, the way which you approach a true resus situation will be different. There is a lot to be said about knowing when to not to do something or to do it in a much more conservative manner. To do so requires understanding more of the how and why which is going to get cut out with shorter schools and lower standards.

If there was a consistently high standard, we wouldn't be fighting things like backboard at the slightest back pain, 15L NRB for a slightly low O2 sat, or flooding trauma patients with liters of saline. Yet it's still done.

I absolutely believe BLS has it's place with most of what we do and ALS is over emphasized. Where I work, it's only just now getting approved that a BLS provider can even tech a 911 call. Just don't cut the standards for ALS, restructure how we operate if anything so each one is being allocated appropriately.

EMT-P/ED RN

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The basic EMT is perfectly suited for less critical calls and, under certain circumstances, are better at it because they think about transport as an immediate intervention. Too often we get stuck on the "stay and play" side of things when "load and go" is what must be done. I'm OK with the basic EMT being the tech on certain calls, as long as I'm reasonably quickly available as an ALS resource because I want them to be a little uncomfortable and I want them to learn how to do very good patient assessments. I want them to learn when to call ALS, when it's appropriate for them to "keep" the patient and when it's appropriate for them to PUHA to the ED because they can get the patient to the ED faster than they can get ALS to the patient.

Now then, when it comes to 911 stuff, I would prefer to have either another Paramedic or an AEMT as a partner because then I have another set of ALS-capable hands for those few times that I would need them. If that's not a possibility, I will absolutely train or want my EMT partner trained to assist me in nearly anything I need done. There's actually very little that's not a monkey skill when it comes to setting up for things... all the "work" is done on my end by determining that a particular thing needs to be done... or not. The AEMT is going to be easier to work with on this end but an EMT is certainly capable of grabbing things and setting up various pieces of equipment.

Why isn't this done more frequently? I suspect it's mostly economics. With the EMT vs AEMT, the EMT is always going to be cheaper. Dual Medic is going to be among the more expensive ways to staff an ambulance. It's also likely done this way because it's often cheaper on the student to go from EMT straight to Paramedic than it is to go EMT to AEMT to Paramedic. Now if you bump the EMT education up to the 600-800 hour range, you might as well get them to the current AEMT level. That means also bumping the AEMT up to the current Paramedic level and the Paramedic should therefore (and be much less common than now) be bumped up to a point where about 80% or so of all CCT stuff can be done by them instead of a dedicated CCT-RN. That also means that the CCT-RN and CFRN gets bumped up significantly as well... so they handle only the most weird and difficult of cases because the Paramedics handle the rest... None of that will be cheap and will only likely make a difference in a very few number of cases. However if you make it your goal, the lower levels get far better at what they do and that's where the patients will see improvements in care.

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In EMT school and your book, almost every scenario is an emergency like strokes, heart attacks, cardiac arrest, etc. When I got out of EMT school, I thought every call was going to be what I thought was 9-1-1 worthy in my mind (you better be dying or else!). In real life, the majority of calls are tummy pain, cold/flu-like symptoms, generalize weakness, mechanical falls, etc. Many of those calls do not require a paramedic. In my system, we are all ALS, but we very infrequently use our ALS skills. I rarely even give oxygen...

The fire extinguisher is not just for show

Not always; we have several AEMTs in our system, and they don't get paid anymore than EMTs. But they have a more difficult credentialing process (all of our trucks have a paramedic on them).

my other system only recognized EMTs and paramedics. We had several people who were AEMTs on the ambulance, as well as a few firefighters on the municipal departments. The medical director only permitted them to function as EMTs. Well, on paper anyway....

And that's the truth. EMS educators try to prepare students for the worse case scenario, when the reality is, most patients simply need a ride to a hospital. some could be treated as well at a local urgent care or PMD.

That doesn't mean that you can't get dispatched to a minor call and the patient need aggressive medical attention or else they are going to die, or you won't have to handle a sick EMS call, but to say that EVERY patient needs ALS or they are going to die is intentionally lying to people at best, fear mongering at worst.

Go on a ride along or two, and see how many patients require ALS interventions, compared to those who just need a ride to the hospital. you will notice a differences.

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You misunderstood my question. Many ALS systems operates with 1 EMT and 1 paramedic on the truck. If the patient requires no ALS interventions, the paramedic drives, and the EMT is in the back with the patient. If they require ALS, the EMT drives. if it's borderline, usually the EMT drives and the paramedic does the stare of life.

So in your ride alongs, with minimal interventions performed, do you think having a paramedic there helped the patient? or could the patient have been treated appropriately with just an EMT crew?